Evidence-Based Review of the Surgical Management
Evidence-Based Review of the Surgical Management
Object: Significant controversy exists over the most appropriate treatment for patients with metastatic disease of the vertebral column. Treatment options include surgical intervention, radiotherapy, or a combination of the two; nevertheless, a standard of care that yields the best survival, outcome, and quality of life has not been established. The purpose of this review was to determine the foundation in the literature of views favoring surgical intervention for spinal metastatic disease.
Methods: A search of the English-language literature published between 1964 and 2003 was performed for the subject of spinal metastatic disease. Papers were selected based on the inclusion criteria described, and evidentiary information was compiled and graded using previously described methods.
Conclusions: Although there is insufficient evidence to support a standard for surgical treatment in patients with metastatic spinal disease, the authors present guidelines and recommendations based on the evidence provided by the current literature.
The spinal column is the most frequent site of bone metastasis. Metastatic spinal disease is a significant problem for a large number of patients: spinal metastases develop in between 5 and 10% of all patients with cancer during the course of their disease. Approximately 40% of persons dying of cancer have autopsy evidence of spinal metastases; 10% of these will experience spinal cord compression with subsequent neurological deficits. The annual incidence of spinal cord compression due to spinal metastases is estimated to be 20,000 cases. In recent autopsy studies, investigators found metastatic involvement of the spine in 90% of patients with prostate carcinoma, in 75% of those with breast carcinoma, 55% of those with melanoma, 45% of those with lung carcinoma, and 30% of those with renal carcinoma. Specific carcinomas cause clinically significant spinal cord compression in a higher percentage of patients. Twenty-two percent of patients with breast cancer, 15% of those with lung cancer, and 10% of those with prostate carcinomas experience symptomatic spinal cord compression.
There is a slight preponderance of metastatic tumors in male (60%) compared with female patients. This sex difference may reflect the incidence of primary breast lesions compared with prostate tumors in published series. All ages of patients may be affected, but the period of highest prevalence coincides with the relatively high cancer risk period that occurs between 40 and 65 years of age.
Metastatic spinal lesions involve the vertebral column and pedicle (85%), the paravertebral spaces (1015%), or the epidural space. The junction of the vertebral body and pedicle is usually the portion of the vertebra involved with metastasis. Metastatic spread to bone may be related to osteotropism of the malignant cells, direct spread, and the highly vascular supply to bone marrow. Seventy percent of cases occur at the thoracic level, 20% at the lumbar region, and 10% at the cervical region. Increased frequency of spinal metastases at the thoracic vertebrae may be related to the fact that there are more thoracic vertebrae than lumbar and cervical ones. Metastatic lesions present initially at multiple, noncontiguous levels in 10 to 38% of cases.
The incidence of metastatic spinal disease is likely to increase in the future. Improvement in diagnostic capabilities, especially the widespread availability and sensitivity of magnetic resonance imaging, may increase the number of patients evaluated and metastatic lesions detected. Progress in many multimodality cancer treatments will prolong patient survival, resulting in more spinal metastases. Screening programs yielding earlier detection of malignant primary lesions will lead to identification of an ever-increasing number of spinal metastases.
Standard treatments for metastatic spinal tumors include radiotherapy alone, radiotherapy plus systemic chemotherapy, hormone therapy, surgical decompression followed by radiotherapy, and, more recently, extracranial radiosurgery. When a metastatic spinal tumor causes compression of the spinal cord or other neural elements, surgical decompression is often chosen. Based on the extent of spinal column destruction and the resulting biomechanical instability of the spine, fixation may be elected. The goal of local radiation therapy in the treatment of spinal metastases has been palliation of painful symptoms, prevention of pathological fractures of the vertebral body, and halting or reversing progression of neurological compromise. The role of radiosurgery has yet to be defined but will likely be limited to treatment of focal disease or use as a supplement to fractionated radiotherapy.
In this evidence-based review we will examine the basis for current clinical practice, focusing on the role of surgery in the management of metastatic spinal column disease.
Metastatic spinal column tumors occur with sufficient frequency to warrant review. The role of surgery in the therapeutic management of vertebral column metastatic disease remains controversial. In 1998, the Canadian Task Force on the Periodic Health Examination produced an evidence-based guideline review of the literature. At the time, the authors concluded that very few papers of high methodological quality had been published, and that more studies were needed to verify the validity of many of the clinical decisions regarding the management of this disease process.
For this review, medical literature addressing surgical management of vertebral column metastatic lesions was examined using the methods of evidence-based medicine to address the following question: "What is the role of surgical management of vertebral column metastatic disease?"
Object: Significant controversy exists over the most appropriate treatment for patients with metastatic disease of the vertebral column. Treatment options include surgical intervention, radiotherapy, or a combination of the two; nevertheless, a standard of care that yields the best survival, outcome, and quality of life has not been established. The purpose of this review was to determine the foundation in the literature of views favoring surgical intervention for spinal metastatic disease.
Methods: A search of the English-language literature published between 1964 and 2003 was performed for the subject of spinal metastatic disease. Papers were selected based on the inclusion criteria described, and evidentiary information was compiled and graded using previously described methods.
Conclusions: Although there is insufficient evidence to support a standard for surgical treatment in patients with metastatic spinal disease, the authors present guidelines and recommendations based on the evidence provided by the current literature.
The spinal column is the most frequent site of bone metastasis. Metastatic spinal disease is a significant problem for a large number of patients: spinal metastases develop in between 5 and 10% of all patients with cancer during the course of their disease. Approximately 40% of persons dying of cancer have autopsy evidence of spinal metastases; 10% of these will experience spinal cord compression with subsequent neurological deficits. The annual incidence of spinal cord compression due to spinal metastases is estimated to be 20,000 cases. In recent autopsy studies, investigators found metastatic involvement of the spine in 90% of patients with prostate carcinoma, in 75% of those with breast carcinoma, 55% of those with melanoma, 45% of those with lung carcinoma, and 30% of those with renal carcinoma. Specific carcinomas cause clinically significant spinal cord compression in a higher percentage of patients. Twenty-two percent of patients with breast cancer, 15% of those with lung cancer, and 10% of those with prostate carcinomas experience symptomatic spinal cord compression.
There is a slight preponderance of metastatic tumors in male (60%) compared with female patients. This sex difference may reflect the incidence of primary breast lesions compared with prostate tumors in published series. All ages of patients may be affected, but the period of highest prevalence coincides with the relatively high cancer risk period that occurs between 40 and 65 years of age.
Metastatic spinal lesions involve the vertebral column and pedicle (85%), the paravertebral spaces (1015%), or the epidural space. The junction of the vertebral body and pedicle is usually the portion of the vertebra involved with metastasis. Metastatic spread to bone may be related to osteotropism of the malignant cells, direct spread, and the highly vascular supply to bone marrow. Seventy percent of cases occur at the thoracic level, 20% at the lumbar region, and 10% at the cervical region. Increased frequency of spinal metastases at the thoracic vertebrae may be related to the fact that there are more thoracic vertebrae than lumbar and cervical ones. Metastatic lesions present initially at multiple, noncontiguous levels in 10 to 38% of cases.
The incidence of metastatic spinal disease is likely to increase in the future. Improvement in diagnostic capabilities, especially the widespread availability and sensitivity of magnetic resonance imaging, may increase the number of patients evaluated and metastatic lesions detected. Progress in many multimodality cancer treatments will prolong patient survival, resulting in more spinal metastases. Screening programs yielding earlier detection of malignant primary lesions will lead to identification of an ever-increasing number of spinal metastases.
Standard treatments for metastatic spinal tumors include radiotherapy alone, radiotherapy plus systemic chemotherapy, hormone therapy, surgical decompression followed by radiotherapy, and, more recently, extracranial radiosurgery. When a metastatic spinal tumor causes compression of the spinal cord or other neural elements, surgical decompression is often chosen. Based on the extent of spinal column destruction and the resulting biomechanical instability of the spine, fixation may be elected. The goal of local radiation therapy in the treatment of spinal metastases has been palliation of painful symptoms, prevention of pathological fractures of the vertebral body, and halting or reversing progression of neurological compromise. The role of radiosurgery has yet to be defined but will likely be limited to treatment of focal disease or use as a supplement to fractionated radiotherapy.
In this evidence-based review we will examine the basis for current clinical practice, focusing on the role of surgery in the management of metastatic spinal column disease.
Metastatic spinal column tumors occur with sufficient frequency to warrant review. The role of surgery in the therapeutic management of vertebral column metastatic disease remains controversial. In 1998, the Canadian Task Force on the Periodic Health Examination produced an evidence-based guideline review of the literature. At the time, the authors concluded that very few papers of high methodological quality had been published, and that more studies were needed to verify the validity of many of the clinical decisions regarding the management of this disease process.
For this review, medical literature addressing surgical management of vertebral column metastatic lesions was examined using the methods of evidence-based medicine to address the following question: "What is the role of surgical management of vertebral column metastatic disease?"
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